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Heart Failure > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

A 76 year male with height 5’8” and weight of 195 pounds presents to the clinic today with complaints of 4 pound weight gain in the past 7 days.
medical history: hypertension (10 years)
Physical exam (today): peripheral edema +1 bilateral rales
Medications: No know drug allergies,
HCTZ 50 mg po daily
metoprolol tartrate (Lopressor®) 12.5 mg po bid
aspirin 162 mg po daily
chest x-ray (today): lower half of each lung has a cloudy appearance.

What would be the most appropriate treatment option at this time?

a. Hold metoprolol and decrease dose of HCTZ to 25 mg daily.
b. Increase metoprolol tartrate (Lopressor®) 25 mg po bid.
c. Discontinue HCTZ then start furosemide 40 mg now and 20 mg po bid.
d. Start lisinopril 10 mg po daily. e. None of the above are justified choices.

A

c. Discontinue HCTZ then start furosemide 40 mg now and 20 mg po bid

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2
Q

During a scheduled clinic visit a 65 year old female complains of increasing shortness of breath when walking up one flight of stairs . She is a non-smoker.
Past medical history: hypertension, hyperlipidemia, Congestive heart failure with left ventricular systolic dysfunction (EF 25%)
Chest X-ray (today): enlarged left ventricle and clear lung fields
Physical exam: Weight (today): 78 kg Weight (3 months ago): 79 kg
Vitals (today): blood pressure 121/72 mmHg heart rate: 65 bpm respiratory rate: 12 breaths per minute
Medications: No known drug allergies pravastatin 40mg po every evening, lisinopril 20mg po daily, furosemide 40mg po bid, potassium chloride 20mEq daily, metoprolol succinate (Toprol-XL®) 100mg po daily

Which of the following recommendations would optimize patient’s drug therapy for heart failure?

a. Change metoprolol succinate (Toprol-XL®) to metoprolol tartrate (IR) to lower risk of mortality as confirmed by the COMET trial. b. Add digoxin to reduce hospitalizations (morbidity) as established by the DIG study. c. Add spironolactone to existing therapy to improve survival and prevent hospitalization with the consideration of lowering potassium supplement and a follow-up serum potassium level.
d. Change lisinopril to ramipril due to the SOLVD trial demonstrating a reduction in mortality and morbidity for heart failure patients.
e. Both b and c are reasonable considerations.

A

e. Both b and c are reasonable considerations.

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3
Q

During a scheduled clinic visit a 65 year old female complains of increasing shortness of breath when walking up one flight of stairs . She is a non-smoker.
Past medical history: hypertension, hyperlipidemia, Congestive heart failure with left ventricular systolic dysfunction (EF 25%)
Chest X-ray (today): enlarged left ventricle and clear lung fields
Physical exam: Weight (today): 78 kg Weight (3 months ago): 79 kg
Vitals (today): blood pressure 121/72 mmHg heart rate: 65 bpm respiratory rate: 12 breaths per minute
Medications: No known drug allergies pravastatin 40mg po every evening, lisinopril 20mg po daily, furosemide 40mg po bid, potassium chloride 20mEq daily, metoprolol succinate (Toprol-XL®) 100mg po daily

What NYHA class & ACC class dose the pt fit into?

A 
NYHA: class 3
ACC: class C
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4
Q

During a scheduled clinic visit a 65 year old female complains of increasing shortness of breath when walking up one flight of stairs . She is a non-smoker.
Past medical history: hypertension, hyperlipidemia, Congestive heart failure with left ventricular systolic dysfunction (EF 25%)
Chest X-ray (today): enlarged left ventricle and clear lung fields
Physical exam: Weight (today): 78 kg Weight (3 months ago): 79 kg
Vitals (today): blood pressure 121/72 mmHg heart rate: 65 bpm respiratory rate: 12 breaths per minute
Medications: No known drug allergies pravastatin 40mg po every evening, lisinopril 20mg po daily, furosemide 40mg po bid, potassium chloride 20mEq daily, metoprolol succinate (Toprol-XL®) 100mg po daily

What lifestyle modification would you recommend to this patient?

A

Stop smoking

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5
Q

During a scheduled clinic visit a 65 year old female complains of increasing shortness of breath when walking up one flight of stairs . She is a non-smoker.
Past medical history: hypertension, hyperlipidemia, Congestive heart failure with left ventricular systolic dysfunction (EF 25%)
Chest X-ray (today): enlarged left ventricle and clear lung fields
Physical exam: Weight (today): 78 kg Weight (3 months ago): 79 kg
Vitals (today): blood pressure 121/72 mmHg heart rate: 65 bpm respiratory rate: 12 breaths per minute
Medications: No known drug allergies pravastatin 40mg po every evening, lisinopril 20mg po daily, furosemide 40mg po bid, potassium chloride 20mEq daily, metoprolol succinate (Toprol-XL®) 100mg po daily

Based on the medication history, this patient is at risk of developing?

A

Hyperkalemia due to the ACEI and potassium supplement

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6
Q

During a scheduled clinic visit a 65 year old female complains of increasing shortness of breath when walking up one flight of stairs . She is a non-smoker.
Past medical history: hypertension, hyperlipidemia, Congestive heart failure with left ventricular systolic dysfunction (EF 25%)
Chest X-ray (today): enlarged left ventricle and clear lung fields
Physical exam: Weight (today): 78 kg Weight (3 months ago): 79 kg
Vitals (today): blood pressure 121/72 mmHg heart rate: 65 bpm respiratory rate: 12 breaths per minute
Medications: No known drug allergies pravastatin 40mg po every evening, lisinopril 20mg po daily, furosemide 40mg po bid, potassium chloride 20mEq daily, metoprolol succinate (Toprol-XL®) 100mg po daily

What comorbidites have increased the pt’s risk of HF?

A

Hypertension

congestive heart failure

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7
Q

A 59 year old male with hight 5’8” and weight of 230 pound is being evaluated today in the hospital from an MI he had 5 days ago after which he had a drug eluting stent placed in his LAD. His chart today indicates pulmonary rales and an echocardiography determines EF of 33%.
Medical history: AMI 5 days ago, hypertension dyslipidemia, smoking a pack of cigarettes per day for the past 25 years
Vitals (today)BP: 138/85 mmHg, HR: 78 bpm.
Medications: No known drug allergies atrovastatin (Lipitor®) 20mg daily, metoprolol tartrate (Lopressor®) 50mg po bid, lisinopril (Zestril®) 20mg po daily, aspirin 162 mg po daily, furosemide (Lasix®) 20mg po bid, nitroglycerin 0.4mg sl prn for chest pain, Nicotine 21 mg apply 1 patch every day
Labs (today): Potassium: 4.0 mEq/L, creatinine 1.1 mg/dL

Based on the EMPHASIS-HF trial, which of the following drug therapy recommendations could be justified for this patient to reduce morbidity and mortality?

a. Change lisinopril to candesartan 4 mg daily. b. Add spironolactone 25 mg po daily.
c. Add eplerenone 25 mg po daily.
d. Add hydrochlorothiazide 12.5 mg daily.
e. None of the above are justified choices based on a specific study.

A

b. Add spironolactone 25 mg po daily.
c. Add eplerenone 25 mg po daily.

B) current guidelines recommend the addition of any aldosterone antagonists in moderate-sever symptoms & reduced LVEF that can be monitored for renal insufficency
C)This is b/c the EMPHASIS-HF trial showed that pts with moderate- severe symptoms of HF (NYHA II) & LVEF reduction = 35% already being treated with an ACEI/ARB + BB do see reduced risk of cardiovascular death & hospitalization if eplerenone is used.

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8
Q

A 59 year old male with hight 5’8” and weight of 230 pound is being evaluated today in the hospital from an MI he had 5 days ago after which he had a drug eluting stent placed in his LAD. His chart today indicates pulmonary rales and an echocardiography determines EF of 33%.
Medical history: AMI 5 days ago, hypertension dyslipidemia, smoking a pack of cigarettes per day for the past 25 years
Vitals (today)BP: 138/85 mmHg, HR: 78 bpm.
Medications: No known drug allergies atrovastatin (Lipitor®) 20mg daily, metoprolol tartrate (Lopressor®) 50mg po bid, lisinopril (Zestril®) 20mg po daily, aspirin 162 mg po daily, furosemide (Lasix®) 20mg po bid, nitroglycerin 0.4mg sl prn for chest pain, Nicotine 21 mg apply 1 patch every day
Labs (today): Potassium: 4.0 mEq/L, creatinine 1.1 mg/dL

Under which circumstances would a substitution of and ACEI to an ARB be appropriate

A

substitution is recommended only if there is an intolerance (cough) to the ACEI. Though ARBs have been substituted if the pt has angioedema, for the test this is a contraindication

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9
Q

which agents are recommended when substituting an ARB for an ACEI?

A

cadnisartan & valsartan

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10
Q

What medications have negative inotropic effects that may precipitate or worsen HF

A 
antiarrhythmic (dispyramide, flecainide, propafenone)
BB
NDHP CCB (verapamil & diltiazem
Oral antifungals ( itraconazole & ternbinafine)
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11
Q

HF can be made worst by cardiotoxic drugs like:

A

doxorubicin, daunorubicin, cyclophosphamide, ehtanol, amphetamines ( cocaine & meth), trastuzumab & imatinib

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12
Q

Drugs such as NSAIDs, glucocorticoids, rosiglitazone & pioglitazone worsen HF by:

A

NSAIDs, glucocorticoids, rosiglitazone & pioglitazone cause Na & water retention = increased volume

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13
Q

What is the definition of acute decompensated heart failure?

A

ADHF is new or worsening signs & symptoms caused by 1) volume overload - wet, 2) hypoperfusion-cold, or both

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14
Q

What the indicators of hypoperfusion

A

hypotension, renal insufficency, shock, or a combination of these

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15
Q

What are the common cause of ADHF

A 
Medication (noncompliance, add neg. inotrop, NSAIDs, alcohol, illicit drug)
Diet noncompliance
A.Fib/ arrhythmias
MI
Uncontrolled HTN
PE
pneumonia
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16
Q

What are the primary symptoms of HF?

A
  1. dyspnea & fatigue
  2. fluid retention
  3. paroxysmal nocturnal dyspnea
  4. orthopnea
  5. tachypnea
  6. cough
  7. ascites
  8. nocturia
17
Q

What are some signs of HF

A
  1. exercise intolerance
  2. pulmonary edema
  3. JVD
  4. hepatojugular reflux
  5. hepatomegaly
  6. pleural effusion
  7. tachycardia
  8. pallor
  9. S3 gallop
18
Q

How is HF diagnosed

A

Increased BNP
ECG for structural or functional changes
ECG,cardiac cath or nuclear imaging for LVEF

19
Q

What is the NYHA/ ACC class for a patient with Past medical history: hypertension, Type 2 DM, obesity and no structural damage to his heart?

A

Only ACC-stage A

20
Q

What is the NYHA/ ACC class for a patient with Past medical history: acute myocardial infarction, renal insufficiency, Type 2 DM, obesity, and echocardiography determines EF of 33% but is able to perform daily activities without any signs of distress?

A

NYHA- Class I, ACC- stage B

21
Q

When should a BB be used in HF

A

Class II-4/ Stage C-D, stable pts W/O fluid overload symptoms or bradycardia, heart block, with symptoms of & low LVEF

22
Q

What is the NYHA/ ACC class for a patient with Past medical history: acute myocardial infarction, renal insufficiency, Type 2 DM, obesity, and echocardiography determines EF of 33% able to perform daily activities, but with some chest pain and SOB after?

A

NYHA- Class II, ACC stage C

23
Q

What is the NYHA/ ACC class for a patient with Past medical history: acute myocardial infarction, renal insufficiency, Type 2 DM, obesity, and echocardiography determines EF of 33% unable to perform daily activities without having chest pain and SOB that only goes away when he stops working?

A

NYHA- Class III, ACC- Stage C

24
Q

What is the NYHA/ ACC class for a patient with Past medical history: acute myocardial infarction, renal insufficiency, Type 2 DM, obesity, and echocardiography determines EF of 33% with chest pain, SOB and palpitations at all times of the day?

A

NYHA- Class IV, ACC- stage D

25
Q

with Past medical history: acute myocardial infarction, congestive heart failure, an EF of 33%, currently taking Enalapril (Vasotec®) 10mg po bid, Lovastatin (Mevacor®) 20mg po daily, Glipizide (Glucotrol®) 10mg bid for Type 2 DM, Nitroglycerin 0.4mg SL prn chest pain,
Aspirin 162 mg po daily, Furosemide (Lasix®) 40mg po bid, Digoxin 0.25 po daily
What is the NYHA/ ACC class of the patient if he is able to perform daily activities with some chest pain, SOB after finishing?

A

NYHA- Class II, ACC- stage C

26
Q

What are the characteristics of patients in NYHA functional class I

A
  1. Have some cardiac disease but

2. are able to perform normal daily activities without ANY symptoms (fatigue, dyspnea, palpitations)

27
Q

What are the characteristics of patients in NYHA functional class II

A
  1. Cardiac disease is present &

2. normal physical activity causes some fatigue, palpitations, dyspnea or anginia

28
Q

What are the characteristics of patients in NYHA functional class III

A
  1. Cardiac disease is present &

2. patient is okay when resting, but small amounts of daily activities cause symptoms

29
Q

What are the characteristics of patients in NYHA functional class IV

A
  1. Cardiac disease

2. unable to do any physical activity without symptoms & have symptoms even at rest

30
Q

What are the characteristics of patients in ACC stage A HF

A
  1. NO cardiac disease
  2. NO symptoms of HF but
  3. Do have risk factors such as HTN, CAD, DM or metabolic syndrome
31
Q

What are the characteristics of patients in ACC stage B HF

A
  1. Structural heart disease present (MI, LVH, low LV syst. function), but
  2. Pt has no symptoms
32
Q

What are the characteristics of patients in ACC stage C HF

A
  1. Structural heart disease &

2. Current or previous HF symptoms (LV systolic dysfucntion- low EF or tx for HF)

33
Q

What are the characteristics of patients in ACC stage D HF

A
  1. Advance structural heart disease
  2. Marked symptoms of HF at rest despite max medical therapy
    (frequent hospitalization for HF, awaiting transplant)
34
Q

You are doing the discharge counseling on a new HF patient. What directions should be given in regards to weight monitoring?

A
  1. Weight should be taken daily (best in the morning, AFTER urination)
35
Q

When should a HF pt contact the doctor about their weight

A
  1. If you have gained >1lb. a day for several consecutive days or
  2. If you have gained 3-5lb. in a week

Heart Failure (2 decks)

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